Estimating tuberculosis burden: national reporting systems
Authors: Ahmad Fuady
Journal: The Lancet Global Health (2022)

Estimating tuberculosis incidence, prevalence, and deaths are crucial to capture the tuberculosis burden and to assess the progress towards tuberculosis elimination in 2035. WHO publishes a report of estimated tuberculosis burden each year, showing that tuberculosis remains among the top ten causes of death worldwide.1WHOGlobal tuberculosis report 2020. World Health Organization, Geneva2020Google Scholar The estimates arise from data and information collected by several methods: surveillance systems, prevalence surveys, mortality surveys, inventory studies (to capture unreported detected tuberculosis), and expert opinion and consultation.2WHOMethods used by WHO to estimate the global burden of TB disease. World Health Organization, Geneva2020Google Scholar Each method and source of data has limitations, including poor data quality and potential biases. Iskandar and colleagues3Iskandar D Suwantika AA Pradipta IS Postma MJ van Boven JFM Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19.Lancet Global Health. 2022; (published online Nov 23.)https://doi.org/10.1016/S2214-109X(22)00455-7Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar reported work in estimating the tuberculosis burden using data from Sistem Informasi Tuberculosis (SITB), an Indonesian national tuberculosis reporting system. This work complements the tuberculosis prevalence survey and inventory study, which had been previously implemented in Indonesia.1WHOGlobal tuberculosis report 2020. World Health Organization, Geneva2020Google Scholar This approach offers an exciting method to inform and facilitate policy decision making in a more efficient way than implementing a tuberculosis prevalence survey and inventory study, which can be costly and logistically challenging. In addition to the increased practicality of this approach, it can also provide more insights on geographical distribution and cost estimates. These estimates can help policy makers to prioritise future interventions to accelerate tuberculosis elimination progress. The SITB is similar to other national tuberculosis reporting systems, such as the Notifiable Diseases Information System in Brazil4Rocha MS Bartholomay P Cavalcante MV et al.Notifiable Diseases Information System (SINAN): main features of tuberculosis notification and data analysis.Epidemiol Serv Saude. 2020; 29e2019017Google Scholar and Tuberculosis Information Management System in China.5Jiang W-X Huang F Tang S-L et al.Implementing a new tuberculosis surveillance system in Zhejiang, Jilin and Ningxia: improvements, challenges and implications for China's National Health Information System.Infect Dis Poverty. 2021; 10: 22Crossref PubMed Scopus (2) Google Scholar Despite the comprehensive data collected in the reporting system, the SITB (and other tuberculosis reporting systems) should still learn from the WHO COVID-19 reporting system. Such a system helps policy makers to take prompt measures to control the spread of infection. Therefore, the tuberculosis reporting system should provide robust, real time, patient-level data linked to a user-friendly interface. However, when patient-level data is used, we must be aware of the limitations. As reported in the study by Iskandar and colleagues,3Iskandar D Suwantika AA Pradipta IS Postma MJ van Boven JFM Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19.Lancet Global Health. 2022; (published online Nov 23.)https://doi.org/10.1016/S2214-109X(22)00455-7Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar the results suggest a lower tuberculosis incidence per 100 000 population than the number reported in the 2020 Global TB report. The SITB mostly provides data on drug-sensitive tuberculosis, and most of these data have been provided by public health-care facilities linked with the National Tuberculosis Program. Therefore, the first issue to resolve is how to engage more private health-care providers in tuberculosis reporting. Despite the high proportion of people seeking tuberculosis care from private health-care providers (given their convenient operating hours and location, flexibility, and perceived better quality),6Victor AA Oladimeji O Horsburgh CR Rethinking Public Private Mix (PPM) performance in the tuberculosis program: how is care seeking impacting this model in high TB burden countries?.Healthcare. 2022; 101285Google Scholar private health-care providers often do not notify tuberculosis cases to national reporting systems, which results in private health-care providers having a low notification rate.7Sunjaya DK Paskaria C Herawati DMD Pramayanti M Riani R Parwati I Initiating a district-based public-private mix to overcome tuberculosis missing cases in Indonesia: readiness to engage.BMC Health Serv Res. 2022; 22: 110Crossref PubMed Scopus (3) Google Scholar Engaging private health-care providers in the tuberculosis reporting system should address the importance of increasing their policy knowledge, limited resources, active participation, and incentives.8Kurniawati A Padmawati RS Mahendradhata Y Acceptability of mandatory tuberculosis notification among private practitioners in Yogyakarta, Indonesia.BMC Res Notes. 2019; 12: 543Crossref PubMed Scopus (12) Google Scholar Second, the improvement of health system capacity is crucial. The findings of geographically unequal distribution of tuberculosis burden are not merely because of the actual incidence, but also discrepancies in health system capacity across regions. Some regions are struggling with reporting, given the scarcity of health-care staff, poor infrastructure, low-level skills and knowledge, and high turnover of health-care workers—all of which can contribute to varying internal consistency and data quality over regions. Third, the tuberculosis control programme should be integrated into a broader national health insurance system pursuing universal health coverage—ie, the tuberculosis reporting system should be integrated with other systems rather than relying on a vertically reporting system of tuberculosis fragmented from the national reporting system.9Hartel LA Yazbeck AS Osewe PL Responding to health system failure on tuberculosis in southern Africa.Health Syst Reform. 2018; 4: 93-100Crossref Scopus (4) Google Scholar Reporting tuberculosis is often abandoned because it is not well connected to the national insurance system and due to an scarcity of incentives. Health-care staff are busy, and given the different systems running simultaneously, they must prioritise which system to comply with. Fourth, developing a real world, patient-level reporting system must address local needs. Strong central government leadership is inevitable, but the system should be flexible to allow local adaptation. The flexibility could allow the inclusion of additional indicators, but not the removal of the leading indicators. The system can also provide cost and budget information, which are often neglected in tuberculosis reporting. However, as reported by Iskandar and colleagues,3Iskandar D Suwantika AA Pradipta IS Postma MJ van Boven JFM Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19.Lancet Global Health. 2022; (published online Nov 23.)https://doi.org/10.1016/S2214-109X(22)00455-7Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar the cost report might be limited to only direct medical costs. Given the high incidence of tuberculosis-related catastrophic costs,10Fuady A Houweling TAJ Mansyur M Richardus JH Catastrophic total costs in tuberculosis-affected households and their determinants since Indonesia's implementation of universal health coverage.Infect Dis Poverty. 2018; 7: 3Crossref PubMed Scopus (64) Google Scholar the system could be expanded to allow other cost estimations—generating information on tuberculosis-related financial burden. The future of tuberculosis burden estimates—from epidemiologic and economic perspectives—is wide open. Tuberculosis burden should be estimated through robust methods. However, the practical policy making practice demands information that can be fast accessed from the actual situation. Using data from the national tuberculosis reporting system to estimate tuberculosis burden is promising. However, although a robust health system demands a comprehensive, unfragmented reporting system, system improvement is a must, together with a future comprehensive and systematic evaluation. I declare no competing interests. Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19Progress was made on drug-susceptible tuberculosis management in Indonesia. However, further intensified efforts, including case-finding, optimising diagnosis, and cost-effective tuberculosis management are required if Indonesia is to achieve the 2025 WHO End Tuberculosis Strategy target incidence of fewer than 55 cases per 100 000 people. These data are an important starting point for understanding drug-susceptible tuberculosis dynamics in Indonesia and optimising its management. Full-Text PDF Open Access